Cognitive-behavioral therapy for adolescent depression: a Meta-analytic investigation of changes in effect-size estimates
Open accessAbstract
Objective To explicate differences between early and recent meta-analytic estimates of the effects of cognitive-behavioral therapy (CBT) for adolescent depression.Method Meta-analytic procedures were used to investigate whether methodological characteristics moderated mean effect sizes among 11 randomized, controlled trials of CBT focusing on adolescents meeting diagnostic criteria for unipolar depression.Results Cumulative meta-analyses indicated that effects of CBT have decreased from large effects in early trials, and confidence intervals have become narrower. Effect sizes were significantly smaller among studies that used intent-to-treat analytic strategies, compared CBT to active treatments, were conducted in clinical settings, and featured greater methodological rigor based on CONSORT (Consolidated Standards of Reporting Trials) criteria. The mean posttreatment effect size of 0.53 was statistically significant.Conclusions Differences in estimates of the efficacy of CBT for depressed adolescents may stem from methodological differences between early and more recent investigations. Overall, results support the effectiveness of CBT for the treatment of adolescent depression.
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The type of control condition selected in an outcome trial is known to significantly affect the effect size observed.
“The type of control condition selected in an outcome trial is known to significantly affect the effect size observed (Klein, Jacobs, & Reinecke, 2007).”
From A randomized controlled trial of strong minds: A school-based mental health program combining acceptance and commitment therapy and positive psychology (2016) · cites this paper as Klein, Jacobs, & Reinecke, 2007
The Results report significantly different effect sizes for CBT trials using inactive versus active or placebo controls. But the analysis covered 11 trials of CBT for adolescent depression, not outcome trials generally; the Discussion also cautions that overlapping methodological characteristics may confound the moderator findings. The source supports an association in this set of trials, rather than an established general effect of control-condition selection. (LLM, conf=0.83)
Experimental — accuracy not yet measuredThe pilot effect size of 0.87 compares favorably with those reported in meta-analysis of clinical trials of standard CBT or antidepressant drugs.
“This magnitude of change compares favorably with those reported in meta–analysis of clinical trials of standard cognitive-behavioral therapy (CBT) or antidepressant drugs (TADS; Kratochvil et al., 2006; ADAPT: Wilkinson et al., 2009), as well as reviews by Klein et al. (2007) and Weisz et al. (2006).”
From A hope intervention for adolescents: a randomized controlled trial delivered by paraprofessionals (2025) · cites this paper as Klein et al., 2007
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Anticipating conflict: Neural correlates of a Bayesian belief and its motor consequence
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“Overall, while the SMA (posterior part of the Brodmann area or BA 6) connects to motor and premotor cortex and responds to movements, the pre-SMA (anterior part of BA 6) connects to other prefrontal structures and responds to cognitive operations whether or not they are related to motor control (Behrens et al., 2006;…”
Wickersham, A., Barack, T., Cross, L., & Downs, J. (2022) · Journal of Medical Internet Research · doi:10.2196/29842 · Cited by 49 · see citing works
“Several reviews and meta-analyses have found it to be an effective treatment method, with improvements maintained during long-term follow-up [8,9].”
MethodWoon, F. L. M., & Hedges, D. W. (2010) · Hippocampus · doi:10.1002/hipo.20746 · Cited by 52 · see citing works
“…volume in PTSD and tested this hypothesis by meta-regression and subgroup analysis (Borenstein et al., 2009), both of which are widely accepted methods to systematically examine a specific moderating effect (Klein et al., 2007; Arnone et al., 2008; Kempton et al., 2008; Rotge et al., 2009).”
MethodProcesses of Change in CBT of Adolescent Depression: Review and Recommendations
Webb, C. A., Auerbach, R. P., & DeRubeis, R. J. (2012) · Journal of Clinical Child & Adolescent Psychology · doi:10.1080/15374416.2012.704842 · Cited by 52 · see citing works
“However, a growing body of research supports the general efficacy of CBT for depression in youth (Klein, Jacobs, & Reinecke, 2007 ; Weersing & Gonzalez, 2009 ; Weisz, McCarty, & Valeri, 2006 ).”
BackgroundFordham, B., Sugavanam, T., Edwards, K., Hemming, K., Howick, J., Copsey, B. J., Lee, H., Kaidesoja, M., Kirtley, S., Hopewell, S., et al. (2021) · Health Technology Assessment · doi:10.3310/hta25090 · Cited by 59 · see citing works
Tak, Y. R., Lichtwarck‐Aschoff, A., Gillham, J. E., Zundert, R. M. P. V., & Engels, R. C. M. E. (2015) · Research on Child and Adolescent Psychopathology · doi:10.1007/s10802-015-0080-1 · Cited by 49 · see citing works
“Finally, the theoretical basis of the program is strong, since it is based upon evidence-based practices that can effectively reduce or prevent depressive symptoms (Calvete et al. 2011; Klein et al. 2007).”
BackgroundWas wirkt in der Therapie von Depression bei Kindern und Jugendlichen wirklich?
Groen, G., & Petermann, F. (2008) · Kindheit und Entwicklung · doi:10.1026/0942-5403.17.4.243 · Cited by 49 · see citing works
Haroz, E. E., Jordans, M. J. D., de Jong, J. T. V. M., Gross, A. L., Bass, J., & Tol, W. A. (2015) · Assessment · doi:10.1177/1073191115612924 · Cited by 48 · see citing works
Ezegbe, B. N., Eseadi, C., Ede, M. O., Igbo, J. N., Anyanwu, J. I., Ede, K. R., Egenti, N. T., Nwokeoma, B. N., Mezieobi, D. I., Oforka, T. O., et al. (2019) · Medicine · doi:10.1097/md.0000000000014935 · Cited by 49 · see citing works
Shirk, S. R., DePrince, A. P., Crisostomo, P. S., & Labus, J. S. (2013) · Psychotherapy · doi:10.1037/a0034845 · Cited by 47 · see citing works
“This pattern of findings is discrepant from results obtained in most efficacy trials of CBT for adolescent depression (Klein et al., 2007).”
ResultDippel, N., Szota, K., Cuijpers, P. J., Christiansen, H., & Brakemeier, E. (2022) · Psychology and Psychotherapy Theory Research and Practice · doi:10.1111/papt.12392 · Cited by 45 · see citing works
Attwood, M., Meadows, S., Stallard, P. N., & Richardson, T. H. (2011) · Child and Adolescent Mental Health · doi:10.1111/j.1475-3588.2011.00627.x · Cited by 45 · see citing works
Korean Medication Algorithm for Depressive Disorders 2017: Third Revision
Seo, J. S., Bahk, W., Wang, H. R., Woo, Y. S., Park, Y. M., Jeong, J., Kim, W. K., Shim, S.-H., Lee, J. G., Jon, D., et al. (2018) · Clinical Psychopharmacology and Neuroscience · doi:10.9758/cpn.2018.16.1.67 · Cited by 44 · see citing works
Evidence for the Efficacy and Effectiveness of Systemic Family Therapy
Carr, A. (2020) · Wiley eBooks · doi:10.1002/9781119438519.ch6 · Cited by 50 · see citing works
Cognitive Behavioral Therapy for Adolescents with ADHD
Antshel, K. M., & Olszewski, A. K. (2014) · Child and Adolescent Psychiatric Clinics of North America · doi:10.1016/j.chc.2014.05.001 · Cited by 44 · see citing works
Cognitive Behaviour Therapy with children who stutter
Kelman, E., & Wheeler, S. (2015) · Procedia - Social and Behavioral Sciences · doi:10.1016/j.sbspro.2015.03.256 · Cited by 44 · see citing works
“such as depression (Compton et al., 2004; Klein et al., 2007); social phobia (Spence et al.”
Nexhmedin Morina, B., Hoppen, T. H., & Kip, A. (2021) · Psychological Medicine · doi:10.1017/s0033291721001641 · Cited by 43 · see citing works
“…2021 at 01:45:21, subject to the Cambridge Core terms of use, available at meta-analyses on the efficacy of psychological interventions for pediatric depression had also found evidence that the effects of psychotherapy for depression have been overestimated (Klein et al., 2007; Weisz et al., 2006).”
BackgroundWilansky, P., Eklund, J., Milner, T., Kreindler, D. M., Cheung, A., Kovacs, T., Shooshtari, S., Astell, A. J., Ohinmaa, A. E., Henderson, J. L., et al. (2016) · JMIR Research Protocols · doi:10.2196/resprot.5841 · Cited by 42 · see citing works
“It has been shown to be an effective treatment for anxiety and depression in children and youth across a wide range of ages [13-19] and using various modes of delivery (eg, individual and group) [20,21].”
Expanding Behavioral Activation to Depressed Adolescents: Lessons Learned in Treatment Development
McCauley, E., Schloredt, K. A., Gudmundsen, G. R., Martell, C. R., & Dimidjian, S. (2011) · Cognitive and Behavioral Practice · doi:10.1016/j.cbpra.2010.07.006 · Cited by 40 · see citing works
Auerbach, R. P., & Ho, M. R. (2012) · Journal of Clinical Child & Adolescent Psychology · doi:10.1080/15374416.2012.727760 · Cited by 41 · see citing works
Hetrick, S. E., Cox, G. R., Fisher, C. A., Bhar, S. S., Rice, S. M., Davey, C. G., & Parker, A. G. (2015) · Early Intervention in Psychiatry · doi:10.1111/eip.12142 · Cited by 39 · see citing works
LeWinn, K. Z., Strigo, I. A., Connolly, C. G., Ho, T. C., Tymofiyeva, O., Sacchet, M. D., Weng, H. Y., Blom, E. H., Simmons, A. N., & Yang, T. T. (2018) · Journal of Affective Disorders · doi:10.1016/j.jad.2018.07.020 · Cited by 38 · see citing works
“Because both behavioral (Cox et al., 2012; Gullone et al., 2010; Klein et al., 2007; Silvers et al., 2012) and neuroimaging (Center for Behavioral Health Statistics and Quality, 2015; McRae et al.”
BackgroundMychailyszyn, M. P., & Elson, D. M. (2018) · Children and Youth Services Review · doi:10.1016/j.childyouth.2018.02.011 · Cited by 27 · see citing works
Mood disorders in childhood and adolescence
Rocha, T. B. M., Zeni, C., Caetano, S. C., & Kieling, C. (2013) · Brazilian Journal of Psychiatry · doi:10.1590/1516-4446-2013-s106 · Cited by 36 · see citing works
Placebo effect in child and adolescent psychiatric trials
Parellada, M., Moreno, C., Moreno, M., Espliego, A., Portugal, E., & Arango, C. (2011) · European Neuropsychopharmacology · doi:10.1016/j.euroneuro.2011.09.007 · Cited by 39 · see citing works
“…trials of controlled cognitivebehavioural therapy (CBT), including adolescents with a diagnosis of depression, has reported that effects of CBT have declined steadily from the large effects reported in early trials, and confidence intervals have become progressively narrower (Klein et al., 2007).”
InfluentialMuris, P., & Ollendick, T. H. (2023) · Clinical Child and Family Psychology Review · doi:10.1007/s10567-023-00425-8 · Cited by 41 · see citing works
“In the case of affective problems, such as social anxiety disorder and depression, cognitive-behavior therapy or interpersonal therapy (possibly in combination with pharmacotherapy, preferably selective serotonin reuptake inhibitors) seems to be clearly indicated (Klein et al., 2007; Soler & Weatherall, 2007; Stangier…”
BackgroundLusk, P., & Melnyk, B. M. (2012) · Journal of Child and Adolescent Psychiatric Nursing · doi:10.1111/jcap.12017 · Cited by 36 · see citing works
Shirk, S. R., Crisostomo, P. S., Jungbluth, N. J., & Gudmundsen, G. R. (2013) · International Journal of Cognitive Therapy · doi:10.1521/ijct.2013.6.4.311 · Cited by 36 · see citing works
Dobson, K. S., Hopkins, J. A., Fata, L., Scherrer, M. C., & Allan, L. C. (2010) · Canadian Journal of School Psychology · doi:10.1177/0829573510386449 · Cited by 35 · see citing works
van den Brink, G., Stapersma, L., Marroun, H. E., Henrichs, J., Szigethy, E., Utens, E. M. W. J., & Escher, J. C. (2016) · BMJ Open Gastroenterology · doi:10.1136/bmjgast-2015-000071 · Cited by 34 · see citing works
Durgam, S., Chen, C., Migliore, R., Prakash, C., Edwards, J. G., & Findling, R. L. (2018) · Pediatric Drugs · doi:10.1007/s40272-018-0290-4 · Cited by 34 · see citing works
Is Treatment Working? Detecting Real Change in the Treatment of Child and Adolescent Depression
Liu, F. F., & Adrian, M. C. (2019) · Journal of the American Academy of Child & Adolescent Psychiatry · doi:10.1016/j.jaac.2019.02.011 · Cited by 34 · see citing works
Ede, M. O., Igbo, J. N., Eseadi, C., Ede, K. R., Ezegbe, B. N., Ede, A. O., Ezurike, C. A., Onwuka, G. T., & Ali, R. B. (2019) · Journal of Rational-Emotive & Cognitive-Behavior Therapy · doi:10.1007/s10942-019-00327-1 · Cited by 38 · see citing works
Rasing, S. P. A., Stikkelbroek, Y. A. J., & Bodden, D. H. M. (2019) · International Journal of Environmental Research and Public Health · doi:10.3390/ijerph17010153 · Cited by 33 · see citing works
“80) [12,13], and only 50% of the treated youth show symptom improvement after psychotherapy [14].”
BackgroundA REVIEW OF PSYCHOTHERAPY OUTCOME RESEARCH: CONSIDERATIONS FOR SCHOOL-BASED MENTAL HEALTH PROVIDERS
Zirkelback, E. A., & Reese, R. J. (2010) · Psychology in the Schools · doi:10.1002/pits.20526 · Cited by 36 · see citing works
Charkhandeh, M., Talib, M. A., & Hunt, C. J. (2016) · Psychiatry Research · doi:10.1016/j.psychres.2016.03.044 · Cited by 34 · see citing works
“Our results support earlier findings of the use of CBT intervention on depression treatment both in Iran and elsewhere in the world (Klein et al., 2007; March et al., 2007; Michael and Crowley, 2002; Qin et al., 2015; Weisz et al., 2006).”
BackgroundResultPsychotherapy of Mood Disorders
Picardi, A., & Gaetano, P. (2014) · Clinical Practice and Epidemiology in Mental Health · doi:10.2174/1745017901410010140 · Cited by 33 · see citing works
“While initial meta-analyses conducted throughout the late 1990s may have overestimated the effect size of CBT, the effectiveness of IPT and CBT for the treatment of depression among adolescents is nevertheless supported by recent reviews, meta-analyses, and clinical trials [58-60].”
Result16 Cognitieve interventies bij kinderen en jongeren
Nauta, M. H., Braet, C., & Scholing, A. (2011) · Bohn Stafleu van Loghum eBooks · doi:10.1007/978-90-313-8310-8_16 · Cited by 32 · see citing works
Stikkelbroek, Y. A. J., Bodden, D. H. M., Deković, M., & van Baar, A. L. (2013) · BMC Psychiatry · doi:10.1186/1471-244x-13-314 · Cited by 32 · see citing works
“Based on previous research [16] an effect size (Cohen’s d) of 0.”
MethodKeleş, S., Munthe, E., & Ruud, E. (2021) · International Journal of Inclusive Education · doi:10.1080/13603116.2021.1979670 · Cited by 31 · see citing works
“We only included studies published in peer-reviewed journals, since the peer review process is one way of attempting to ensure methodological rigour (Klein, Jacobs, and Reinecke 2007).”
MethodThe unfulfilled promise of the antidepressant medications
Davey, C. G., & Chanen, A. M. (2016) · The Medical Journal of Australia · doi:10.5694/mja16.00194 · Cited by 32 · see citing works
Shafran, R., Bennett, S. D., Coughtrey, A. E., Welch, A., Walji, F., Cross, J. H., Heyman, I., Sibelli, A., Smith, J. S., Ross, J., et al. (2020) · Clinical Child and Family Psychology Review · doi:10.1007/s10567-019-00310-3 · Cited by 30 · see citing works
Simmons, M. B., Hetrick, S. E., & Jorm, A. F. (2013) · BMC Psychiatry · doi:10.1186/1471-244x-13-335 · Cited by 31 · see citing works
“A recent meta-analysis of CBT for adolescent depression demonstrated a decrease in effect size over time [14].”
MethodGipson, P. Y., & King, C. A. (2011) · Cognitive and Behavioral Practice · doi:10.1016/j.cbpra.2010.11.005 · Cited by 28 · see citing works
Jacob, M. K., Keeley, M. L., Ritschel, L. A., & Craighead, W. E. (2011) · Clinical Psychology & Psychotherapy · doi:10.1002/cpp.774 · Cited by 28 · see citing works
COPE for the Treatment of Depressed Adolescents
Lusk, P., & Melnyk, B. M. (2011) · Journal of the American Psychiatric Nurses Association · doi:10.1177/1078390311416117 · Cited by 28 · see citing works
Psychological treatment for adolescent depression: perspectives on the past, present, and future
Hayes, L., Bach, P. A., & Boyd, C. P. (2010) · Behaviour Change · doi:10.1375/bech.27.1.1 · Cited by 28 · see citing works
“Klein, Jacobs, and Reinecke (2007) also used effect size analysis but restricted their comparison to adolescents with a diagnosis of depression.”
BackgroundMethodFamily-Based Crisis Intervention in the Emergency Department: A New Model of Care
Ginnis, K. B., White, E. M., Ross, A. M., & Wharff, E. A. (2013) · Journal of Child and Family Studies · doi:10.1007/s10826-013-9823-1 · Cited by 27 · see citing works
“There is a strong body of literature that supports their use in decreasing depressive symptoms (Klein et al. 2007; Spirito et al. 2011).”
BackgroundHyde, A. J., May, B. H., Xue, C. C., & Zhang, A. L. (2017) · American Journal of Geriatric Psychiatry · doi:10.1016/j.jagp.2017.02.022 · Cited by 27 · see citing works
Liang, J., Li, J., Wu, R.-K., Li, J., Qian, S., Jia, R., Ying-quan, W., Qian, Y., & Xu, Y. (2020) · European Child & Adolescent Psychiatry · doi:10.1007/s00787-020-01492-w · Cited by 30 · see citing works
Reinecke, M. A., Curry, J. F., & March, J. S. (2009) · Journal of Clinical Child & Adolescent Psychology · doi:10.1080/15374410903258991 · Cited by 27 · see citing works
“The results of TADS are congruent with other research in suggesting that CBT may be efficacious for treating depression among adolescents (for reviews, see Curry, 2001 ; David-Ferdon & Kaslow, 2008 ; Fonagy, Target, Cottrell, Phillips, & Kurtz, 2002; Klein, Jacobs, & Reinecke, 2007 ; Weisz, McCarty, & Valeri, 2006), a…”
ResultSelf-citationHoppen, T. H., & Nexhmedin Morina, B. (2020) · Clinical Psychology Review · doi:10.1016/j.cpr.2020.101855 · Cited by 27 · see citing works
A Multi‐Family Group Intervention for Adolescent Depression: The BEST MOOD Program
Poole, L. A., Lewis, A. J., Toumbourou, J. W., Knight, T., Bertino, M. D., & Pryor, R. (2016) · Family Process · doi:10.1111/famp.12218 · Cited by 25 · see citing works
Psychological management of unipolar depression
Lampe, L. A., Coulston, C. M., & Berk, L. (2013) · Acta Psychiatrica Scandinavica · doi:10.1111/acps.12123 · Cited by 24 · see citing works
“In a meta-analysis of 20 studies (106), the mean weighted post-treatment effect size of CBT was 0.”
- Authors
- KLEIN, J. B., JACOBS, R. H., & REINECKE, M. A.
- Affiliations
- Northwestern University (US)
- Corresponding author
- KLEIN, JESSE B.
- ORCID
- JACOBS, RACHEL H.
- Venue
- Journal of the American Academy of Child & Adolescent Psychiatry
- Publisher
- Elsevier BV
- Published
- 2007-11
- Volume
- 46
- Issue
- 11
- Pages
- 1403-1413
- ISSN
- 0890-8567 (ISSN-L)
- PMC
- PMC2270481
- OpenAlex
- W2074331965
- Cited by
- 254
- References
- 43
- Citations by year
- 2026: 4 · 2025: 13 · 2024: 6 · 2023: 10 · 2022: 13 · 2021: 13 · 2020: 25 · 2019: 18 · 2018: 16 · 2017: 9 · 2016: 20 · 2015: 19 · 2014: 13 · 2013: 22 · 2012: 10
- FWCI
- 1.59
- Type
- journal article
- Language
- en
- Open access
- green
- www.ncbi.nlm.nih.gov
- Locations
- Journal of the American Academy of Child & Adolescent Psychiatry (publishedVersion)
- PubMed (publishedVersion)
- PubMed Central (acceptedVersion)
- Funders
- National Institute of Mental Health (F31MH075308)
- Topics
- Social Sciences › Psychology › Clinical Psychology › Psychotherapy Techniques and Applications
- Social Sciences › Psychology › Experimental and Cognitive Psychology › Anxiety, Depression, Psychometrics, Treatment, Cognitive Processes
- Social Sciences › Psychology › Clinical Psychology › Psychological Treatments and Assessments
- Keywords
- cognitive behavioral therapy, adolescent depression, major depressive disorder, treatment efficacy, effect size heterogeneity, methodological quality, intention-to-treat analysis, clinical trial design
- MeSH terms
- Adolescent, Major Depressive Disorder, Humans, Cognitive Behavioral Therapy, Treatment Outcome
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